23 Telescopic Intraocular Lenses Abstract The telescopic intraocular lenses (IOL) are specifically helpful in cases with macular degeneration. The telescopic IOL magnifies the image on the central retina, while the peripheral field remains normal. Hence, the IOL helps patients with central visual impairment as in macular degeneration to see the objects clearly. Keywords: telescopic IOL, macular degeneration, AMD, dry AMD, wet AMD, central vision loss With an aging population and with the increased longevity that modern medicine has made possible, there is an increasing population of cataract patients with other associated eye diseases such as age-related macular degeneration (AMD), diabetes, etc., thus presenting to the eye surgeon with a complex situation. The difficulties that comorbid pathologies induce are being experienced by surgeons all over the world. The prevalence of AMD in Asia has been found to be similar to that in Caucasian populations and has been variously reported as ranging from 1.4 to 12.7% for early AMD and 0.2 to 1.9% for late AMD. The presence of cortical cataract and prior cataract surgery are significantly associated with increased prevalence of AMD, showing that these age-related conditions often coexist. Dry AMD constitutes 85 to 90% of AMD patients and most of these patients have no medical treatment at all, other than vitamins and antioxidants. These patients can be treated only with optical means. Among the wet ARMD, only 10 to 15% can be assisted by medical treatment and these go on to become the dry types, who then again need to be visually rehabilitated. The important factor to realize here is that despite performing cataract surgery1,2 successfully in these patients, they do not benefit as much visually because of the coexisting retinal pathology. There is, therefore, a significant difference between treating the disease pathology with medical management/lasers/cataract surgery and with being able to successfully rehabilitate the patient visually. Visual benefits from treatment are after all what actually affects the quality of life of the patient and what is meaningful to the patient. Cataract surgery per se is not a problem in eyes with AMD, but lack of post-op visual improvement is definitely a cause of concern. One of us (Dr. Isaac Lipshitz) designed the LMI-SI (OriLens), which is a telescopic lens working on the principle of using mirrors to magnify the central image while the peripheral field remains normal. The LMI is designed in such a way that it is positioned in the sulcus over a regular bag implanted IOL. It is a telescopic IOL that is designed to magnify the image on the central retina. It looks like a regular polymethyl methacrylate (PMMA) IOL and is 5.00 to 6.00 mm in diameter (loop diameter is 13.50 mm), and it contains loops that have a similar configuration as a regular IOL. The only significant difference compared to a regular IOL is its central thickness. The LMI is thicker (central thickness of 1.25 mm, which is higher thickness than a normal IOL). The first worldwide implantation of this lens was done by Prof. Amar Agarwal. Preoperatively, as soon as a patient with AMD comes, a full medical eye examination including slit lamp for evaluation of the cornea, iris, anterior chamber, lens, and vitreous is done. A thorough retinal examination is done including fundus fluorescein angiography and optical coherence tomography, and the IOP is checked. The distance and near visual acuity are checked in each eye separately using the Early Treatment Diabetic Retinopathy Study (ETDRS) chart with best correction. The best corrected, distance, and near visual acuity with × 2.5 external telescope is again checked using the ETDRS chart. If a patient shows improvement with the external telescope, he or she is a good candidate for the LMI-SI (OriLens). A cycloplegic refraction is also done. Specular microscopy is done for endothelial cell count. A-scan is done for anterior chamber depth and IOL calculations. Keratometric readings are taken with the keratometer or with corneal topography. Intraoperatively, anesthesia is given according to the surgeon’s preference. A corneal or limbal incision may be used and the size of the incision is made according to the surgical technique used. If the eye is phakic, a routine phaco or extracapsular cataract extraction (ECCE) procedure is performed and the IOL (power calculated according to biometry) planned for the patient is inserted into the capsular bag ( Postoperative care is similar to that of a regular cataract extraction except that a closer watch is kept for anterior synechiae and IOP spike. Post-op tests are carried out at days 1, 2, 7, and 30, and 3, 6, and 12 months. The centration and position of the lens are checked for and the patient is refracted for distance and near uncorrected and best corrected visual acuity using the ETDRS chart (each eye separately). Postoperative specular microscopy is done. The initial outcomes are encouraging and a trial with larger number of patients recruited and a longer follow-up is being planned. Proper patient recruitment is a key factor in ensuring good outcomes as in every other case. The inclusion criteria for our pilot trial of the LMI-SI (OriLens) included patients with bilateral AMD (dry type, wet type, scar stage) or other similar macular lesions where the visual acuity ranged between 20/60 and 20/600 in each eye and improved for distance and/or near when tested with a × 2.5 magnification using an external telescope. Presence of any other systemic or ocular diseases (other than cataract/pseudophakia, AMD, or another macular lesion) excluded them, as also any other previous eye surgery other than cataract. Only those patients who were easy to communicate with, responsible, and understood his or her condition, who knew the risks and potential benefits involved, and who were highly motivated to read and improve visual capabilities were included. It was made sure that they understood that they would have to be available for follow-up of 1 year post-op. All the patients signed an informed consent. All other patients were excluded, as also those patients in whom the fellow eye suffers from medical problems, which would not enable the patient to use his peripheral vision, for example, those with glaucoma or retinitis pigmentosa.
23.1 Introduction
23.2 A New Sulcus Implanted Mirror Telescopic IOL for AgeRelated Macular Diseases and Other Macular Disorders the LMI-SI (OriLens)
23.3 Preoperative Evaluation
23.4 Surgery for Implanting the LMI-SI (OriLens)
Fig. 23.1). The incision is then enlarged to 5 to 5.50 mm. The anterior chamber is filled with viscoelastic and the implant is also coated with viscoelastic (
Fig. 23.2). It is then grasped by the loops or the base of the loop, taking care not to touch the lens optic itself (
Fig. 23.3). It is inserted into the sulcus as a piggyback IOL with the posterior mirror (ring shaped) pointing toward the surgeon (
Fig. 23.4, 
Fig. 23.5). It is confirmed that the pupil on the operated eye is central. In case of an eccentric pupil, a pupilloplasty may be needed. A peripheral iridectomy is then done surgically (yttrium aluminum garnet laser should not be used). All the viscoelastic is removed and the incision is sutured.
23.5 Results
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